Myocardial Infarction Nursing Care Plan & Management

Notes

Description

Refers to a dynamic process by which one or more regions of the heart muscle experience a severe and prolonged decrease in oxygen supply because of insufficient coronary blood flow. The affected muscle tissue subsequently becomes necrotic.

Onset of Myocardial Infarction may be sudden or gradual, and the process takes 3 to 6 hours to run its course.

It is the most serious manifestation of acute coronary syndrome, a complication of coronary artery disease (CAD).

Approximately 90% of Myocardial Infarction are precipitated by acute coronary thrombosis (partial or total) secondary to severe CAD (greater than 70% narrowing of the artery).

Risk Factors

Modifiable

Infarctions may occur for a variety of reasons, but coronary thrombosis of a coronary artery narrowed with plaque is the most common cause.

Other causes include spasms of the coronary arteries; blockage of the coronary arteries by embolism of thrombi, fatty plaques, air, or calcium; and disparity between myocardial oxygen demand and coronary arterial supply.

Multiple risk factors have been identified for coronary artery disease and MI.

Modifiable risk factors include cigarette smoking, which causes arterial vasoconstriction and increases plaque formation. A diet high in saturated fats, cholesterol, sugar, salt, and total calories increases the risk for MIs. Elevated serum cholesterol and low-density lipoprotein levels increase the chance for atherosclerosis. Hypertension and obesity increase the workload of the heart, and diabetes mellitus decreases the circulation to the heart muscle.

Hostility and stress may also increase sympathetic nervous system activity and pose risk.

A sedentary lifestyle diminishes collateral circulation and decreases the strength of the cardiac muscle.

Medications can also prevent risks.

Oral contraceptives may enhance thrombus formation, cocaine use can cause coronary artery spasm, and anabolic steroid use can accelerate atherosclerosis.

Non-Modifiable

Some factors—such as age, family history, and gender—cannot be modified.

Aging increases the atherosclerotic process, family history may increase the risk by both genetic and environmental influences, and males are more prone to MIs than are premenopausal women.

Premenopausal women have the benefit of protective estrogens and a lower hematocrit, although heart disease is on the rise in this population, possibly because of an increased rate of smoking in women. Once women become postmenopausal, their risk for MI increases, as it also does for men over age 50.

Assessment

Chest pain

Character: variable, but often diffuse, steady substernal chest pain. Other sensations include a crushing and squeezing feeling in the chest. Other sensations include a crushing and squeezing feeling in the chest.

Severity: pain may be severe; not relieved by rest or sublingual vasodilator therapy, requires opioids.

Location: variable, but often pain resides behind upper or middle third of sternum.

Radiation: pain may radiate to the arms (commonly the left), and to the shoulders, neck, back, or jaw.

Nonspecific enzymes including aspartate transaminase, lactate dehydrogenase, and myoglobulin may be elevated.

More specific creatinine phosphokinase isoenzyme CK-MB will be elevated.

Triponin T and I are myocardial proteins that increase in the serum about 3 to 4 hours after an MI, peak in 4 to 24 hours, and are detectable for upto 2 weeks; the test is easy to run, can help diagnose an MI up to 2 weeks earlier, and only unstable angina causes a false positive.

Pharmacologic Intervention

Thrombolytic therapy by I.V. or intracoronary route, to dissolve thrombus formation and reduce the size of the infarction.

Anticoagulants or other anti-platelet medications such as adjunct to thrombolytic therapy.

Reperfusion arrhythmias may follow successful therapy.

Beta-adrenergic blockers, to improve oxygen supply and demand, decrease sympathetic stimulation to the heart, promote blood flow in the small vessels of the heart, and provide antiarrhythmic effects.

Calcium channel blockers, to improve oxygen supply and demand.

Nursing Interventions

Monitor continuous ECG to watch for life threatening arrhythmias (common within 24 hours after infarctions) and evolution of the MI (changes in ST segments and T waves). Be alert for any type of premature ventricular beats- these may herald ventricular fibrillation or ventricular tachycardia.

Discharge and Home Healthcare Guidelines

Be sure the patient understands all the medications, including the dosage, route, action, and adverse effects. Instruct the patient to keep the nitroglycerin bottle sealed and away from heat.

The medication may lose its potency after the bottle has been opened for 6 months. If the patient does not feel a sensation when the tablet is put under the tongue or does not get a headache, the pills may have lost their potency.

Explain the need to treat recurrent chest pain or MI discomfort with sublingual nitroglycerin every 5 minutes for three doses. If the pain persists for 20 minutes, teach the patient to seek medical attention. If the patient has severe pain or becomes short of breath with chest pain, teach the patient to take nitroglycerin and seek medical attention right away. Explore mechanisms to implement diet control, an exercise program, and smoking cessation if appropriate.

Exam

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Question 1

What is the most common complication of an MI?

A

Cardiogenic shock

B

Heart failure

C

arrhythmias

D

Pericarditis

Question 1 Explanation:

Arrhythmias, caused by oxygen deprivation to the myocardium, are the most common complication of an MI.

Option A: Cardiogenic shock, another complication of an MI, is defined as the end stage of left ventricular dysfunction. This condition occurs in approximately 15% of clients with MI.

Option B: Because the pumping function of the heart is compromised by an MI, heart failure is the second most common complication.

Option D: Pericarditis most commonly results from a bacterial or viral infection but may occur after the MI.

Question 2

An early finding in the EKG of a client with an infarcted mycardium would be:

A

Disappearance of Q waves

B

Elevated ST segments

C

Absence of P wave

D

Flattened T waves

Question 2 Explanation:

This is a typical early finding after a myocardial infarct because of the altered contractility of the heart. The other choices are not typical of MI.

Question 3

Which of the following is an expected outcome for a client on the second day of hospitalization after an MI?

A

Has severe chest pain

B

Can identify risks factors for MI

C

Agrees to participate in a cardiac rehabilitation walking program

D

Can perform personal self-care activities without pain

Question 3 Explanation:

By day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without chest pain. Day 2 hospitalization may be too soon for clients to be able to identify risk factors for MI or begin a walking program; however, the client may be sitting up in a chair as part of the cardiac rehabilitation program. Severe chest pain should not be present.

Question 4

Which of the following recurring conditions most commonly occurs in clients with cardiomyopathy?

A

Heart failure

B

Diabetes

C

MI

D

Pericardial effusion

Question 4 Explanation:

Because the structure and function of the heart muscle is affected, heart failure most commonly occurs in clients with cardiomyopathy.

Option C: MI results from prolonged myocardial ischemia due to reduced blood flow through one of the coronary arteries.

Option D: Pericardial effusion is most predominant in clients with pericarditis.

Question 5

Which of the following is the most common symptom of myocardial infarction?

A

Chest pain

B

Dyspnea

C

Edema

D

Palpitations

Question 5 Explanation:

The most common symptom of an MI is chest pain, resulting from deprivation of oxygen to the heart. Dyspnea is the second most common symptom, related to an increase in the metabolic needs of the body during an MI. Edema is a later sign of heart failure, often seen after an MI. Palpitations may result from reduced cardiac output, producing arrhythmias.

Question 6

Nurse Betty is assigned to the following clients. The client that the nurse would see first after endorsement?

A

A 34 year-old post operative appendectomy client of five hours who is complaining of pain.

B

A 44 year-old myocardial infarction (MI) client who is complaining of nausea.

A 63 year-old post operative’s abdominal hysterectomy client of three days whose incisional dressing is saturated with serosanguinous fluid.

Question 6 Explanation:

Nausea is a symptom of impending myocardial infarction (MI) and should be assessed immediately so that treatment can be instituted and further damage to the heart is avoided.

Question 7

The client with an acute myocardial infarction is hospitalized for almost one week. The client experiences nausea and loss of appetite. The nurse caring for the client recognizes that these symptoms may indicate the:

Which of the following symptoms is the most likely origin of pain the client described as knifelike chest pain that increases in intensity with inspiration?

A

Cardiac

B

Gastrointestinal

C

Musculoskeletal

D

Pulmonary

Question 8 Explanation:

Pulmonary pain is generally described by these symptoms.

Options A and B: Cardiac and GI pains don’t change with respiration.

Option C: Musculoskeletal pain only increases with movement.

Question 9

Dr. Marquez orders a continuous intravenous nitroglycerin infusion for the client suffering from myocardial infarction. Which of the following is the most essential nursing action?

A

Monitoring urine output frequently

B

Monitoring blood pressure every 4 hours

C

Obtaining serum potassium levels daily

D

Obtaining infusion pump for the medication

Question 9 Explanation:

Administration of Intravenous Nitroglycerin infusion requires pump for accurate control of medication.

Question 10

A 23 year old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?

A

Myocardial infarction due to a history of atherosclerosis.

B

Pulmonary embolism due to deep vein thrombosis (DVT).

C

Anxiety attack due to worries about her baby's health.

D

Congestive heart failure due to fluid overload.

Question 10 Explanation:

In a hospitalized patient on prolonged bed rest, he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. Myocardial infarction and atherosclerosis are unlikely in a 27-year-old woman, as is congestive heart failure due to fluid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms, the seriousness of pulmonary embolism demands that it be considered first.

Question 11

Which of the following complications is indicated by a third heart sound (S3)?

A

Ventricular dilation

B

Systemic hypertension

C

Aortic valve malfunction

D

Increased atrial contractions

Question 11 Explanation:

Rapid filling of the ventricle causes vasodilation that is auscultated as S3.

Option B and D: Increased atrial contraction or systemic hypertension can result in a fourth heart sound.

Option C: Aortic valve malfunction is heard as a murmur.

Question 12

During the second day of hospitalization of the client after a Myocardial Infarction. Which of the following is an expected outcome?

A

Able to perform self-care activities without pain

B

Severe chest pain

C

Can recognize the risk factors of Myocardial Infarction

D

Can participate in cardiac rehabilitation walking program

Question 12 Explanation:

By the 2nd day of hospitalization after suffering a Myocardial Infarction, Clients are able to perform care without chest pain

A normal apical impulse is found under over the apex of the heart and is typically located and auscultated in the left fifth intercostal space in the midclavicular line. An apical impulse located or auscultated below the fifth intercostal space or lateral to the midclavicular line may indicate left ventricular enlargement.

Question 14

A patient arrives in the emergency department with symptoms of myocardial infarction, progressing to cardiogenic shock. Which of the following symptoms should the nurse expect the patient to exhibit with cardiogenic shock?

A

Hypertension.

B

Bradycardia.

C

Bounding pulse.

D

Confusion.

Question 14 Explanation:

Cardiogenic shock severely impairs the pumping function of the heart muscle, causing diminished blood flow to the organs of the body. This results in diminished brain function and confusion, as well as hypotension, tachycardia, and weak pulse. Cardiogenic shock is a serious complication of myocardial infarction with a high mortality rate.

Question 15

Which of the following heart muscle diseases is unrelated to other cardiovascular disease?

A

Cardiomyopathy

B

Coronary artery disease

C

Myocardial infarction

D

Pericardial effusion

Question 15 Explanation:

Cardiomyopathy isn’t usually related to an underlying heart disease such as atherosclerosis. The etiology in most cases is unknown.

Options B and C: CAD and MI are directly related to atherosclerosis.

Option D:Pericardial effusion is the escape of fluid into the pericardial sac, a condition associated with Pericarditis and advanced heart failure.

Question 16

An older, sedentary adult may not respond to emotional or physical stress as well as a younger individual because of:

A

Left ventricular atrophy

B

Irregular heartbeats

C

peripheral vascular occlusion

D

Pacemaker placement

Question 16 Explanation:

In older adults who are less active and do not exercise the heart muscle, atrophy can result. Disuse or deconditioning can lead to abnormal changes in the myocardium of the older adult. As a result, under sudden emotional or physical stress, the left ventricle is less able to respond to the increased demands on the myocardial muscle.

Question 17

Medical treatment of coronary artery disease includes which of the following procedures?

In which of the following types of cardiomyopathy does cardiac output remain normal?

A

Dilated

B

Hypertrophic

C

Obliterative

D

Restrictive

Question 20 Explanation:

Cardiac output isn’t affected by hypertrophic cardiomyopathy because the size of the ventricle remains relatively unchanged. All of the rest decrease cardiac output.

Question 21

Septal involvement occurs in which type of cardiomyopathy?

A

Congestive

B

Dilated

C

Hypertrophic

D

Restrictive

Question 21 Explanation:

In hypertrophic cardiomyopathy, hypertrophy of the ventricular septum—not the ventricle chambers—is apparent. This abnormality isn’t seen in other types of cardiomyopathy.

Question 22

If medical treatments fail, which of the following invasive procedures is necessary for treating cariomyopathy?

A

Cardiac catherization

B

Coronary artery bypass graft (CABG)

C

Heart transplantation

D

Intra-aortic balloon pump (IABP)

Question 22 Explanation:

The only definitive treatment for cardiomyopathy that can’t be controlled medically is a heart transplant because the damage to the heart muscle is irreversible.

Question 23

After an anterior wall myocardial infarction, which of the following problems is indicated by auscultation of crackles in the lungs?

A

Left-sided heart failure

B

Pulmonic valve malfunction

C

Right-sided heart failure

D

Tricupsid valve malfunction

Question 23 Explanation:

The left ventricle is responsible for most of the cardiac output. An anterior wall MI may result in a decrease in left ventricular function. When the left ventricle doesn’t function properly, resulting in left-sided heart failure, fluid accumulates in the interstitial and alveolar spaces in the lungs and causes crackles.

HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart muscle becomes weak and does not adequately pump the blood out of the chambers. As a result, blood pools in the left ventricle and backs up into the left atrium, and eventually into the lungs. Therefore, greater amounts of blood remain in the ventricle after contraction thereby decreasing cardiac output. In addition, this pooling leads to thrombus formation and ineffective tissue perfusion because of the decrease in blood flow to the other organs and tissues of the body. Typically, these clients have an ejection fraction of less than 50% and poorly tolerate activity.

Option B: Activity intolerance is related to a decrease, not increase, in cardiac output.

Option D: Gas exchange is impaired. However, the decrease in cardiac output triggers compensatory mechanisms, such as an increase in sympathetic nervous system activity.

Question 25

A client comes into the E.R. with acute shortness of breath and a cough that produces pink, frothy sputum. Admission assessment reveals crackles and wheezes, a BP of 85/46, a HR of 122 BPM, and a respiratory rate of 38 breaths/minute. The client’s medical history included DM, HTN, and heart failure. Which of the following disorders should the nurse suspect?

The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question?

A

"You need to regain your strength before attempting such exertion."

B

"When you can climb 2 flights of stairs without problems, it is generally safe.”

C

"Have a glass of wine to relax you, then you can try to have sex."

D

"If you can maintain an active walking program, you will have less risk."

Question 26 Explanation:

"When you can climb 2 flights of stairs without problems, it is generally safe." There is a risk of cardiac rupture at the point of the myocardial infarction for about 6 weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care providers.

Question 27

A client with pulmonary edema has been on diuretic therapy. The client has an order for additional furosemide (Lasix) in the amount of 40 mg IV push. Knowing that the client also will be started on Digoxin (Lanoxin), a nurse checks the client’s most recent:

A

Digoxin level

B

Sodium level

C

Potassium level

D

Creatinine level

Question 27 Explanation:

The serum potassium level is measured in the client receiving digoxin and furosemide. Heightened digitalis effect leading to digoxin toxicity can occur in the client with hypokalemia. Hypokalemia also predisposes the client to ventricular dysrhythmias.

Question 28

Following myocardial infarction, a hospitalized patient is encouraged to practice frequent leg exercises and ambulate in the hallway as directed by his physician. Which of the following choices reflects the purpose of exercise for this patient?

A

Increases fitness and prevents future heart attacks.

B

Prevents bedsores.

C

Prevents DVT (deep vein thrombosis).

D

Prevent constipations.

Question 28 Explanation:

Exercise is important for all hospitalized patients to prevent deep vein thrombosis. Muscular contraction promotes venous return and prevents hemostasis in the lower extremities. This exercise is not sufficiently vigorous to increase physical fitness, nor is it intended to prevent bedsores or constipation.

Question 29

On the evening shift, the triage nurse evaluates several clients who were brought to the emergency department. Which in the following clients should receive highest priority?

A

an elderly woman complaining of a loss of appetite and fatigue for the past week

B

A football player limping and complaining of pain and swelling in the right ankle

C

A 50-year-old man, diaphoretic and complaining of severe chest pain radiating to his jaw

D

A mother with a 5-year-old boy who says her son has been complaining of nausea and vomited once since noon

Question 29 Explanation:

These are likely signs of an acute myocardial infarction (MI). An acute MI is a cardiovascular emergency requiring immediate attention. Acute MI is potentially fatal if not treated immediately.

Question 30

Twenty four hours after admission for an Acute MI, Jose’s temperature is noted at 39.3 C. The nurse monitors him for other adaptations related to the pyrexia, including:

A

Shortness of breath

B

Chest pain

C

Elevated blood pressure

D

Increased pulse rate

Question 30 Explanation:

Fever causes an increase in the body’s metabolism, which results in an increase in oxygen consumption and demand. This need for oxygen increases the heart rate, which is reflected in the increased pulse rate. Increased BP, chest pain and shortness of breath are not typically noted in fever.

Question 31

Which of the following conditions is associated with a predictable level of pain that occurs as a result of physical or emotional stress?

A

Anxiety

B

Stable angina

C

Unstable angina

D

Variant angina

Question 31 Explanation:

The pain of stable angina is predictable in nature, builds gradually, and quickly reaches maximum intensity.

Option D: Variant angina usually occurs at rest—not as a result of exercise or stress.

Question 32

A client who had cardiac surgery 24 hours ago has a urine output averaging 19 ml/hr for 2 hours. The client received a single bolus of 500 ml of IV fluid. Urine output for the subsequent hour was 25 ml. Daily laboratory results indicate the blood urea nitrogen is 45 mg/dL and the serum creatinine is 2.2 mg/dL. A nurse interprets the client is at risk for:

A

Hypovolemia

B

UTI

C

Glomerulonephritis

D

Acute renal failure

Question 32 Explanation:

The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal insult is signaled by decreased urine output, and increased BUN and creatinine levels. The client may need medications such as dopamine (Intropin) to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis.

Question 33

Which of the following conditions is the predominant cause of angina?

A

Increased preload

B

Decreased afterload

C

Coronary artery spasm

D

Inadequate oxygen supply to the myocardium

Question 33 Explanation:

Inadequate oxygen supply to the myocardium is responsible for the pain accompanying angina.

A 42-year-old client admitted with an acute myocardial infarction asks to see his chart. What should the nurse do first?

A

Allow the client to view his chart

B

Contact the supervisor and physician for approval

C

Ask the client if he has concerns about his care

D

Tell the client that he isn't permitted to view his chart.

Question 35

Which of the following foods should the nurse teach a client with heart failure to avoid or limit when following a 2-gram sodium diet?

A

Apples

B

Tomato juice

C

Whole wheat bread

D

Beef tenderloin

Question 35 Explanation:

Canned foods and juices, such as tomato juice, are typically high in sodium and should be avoided in a sodium-restricted diet.

Question 36

In order to be effective, Percutaneous Transluminal Coronary Angioplasty (PTCA) must be performed within what time frame, beginning with arrival at the emergency department after diagnosis of myocardial infarction?

A

60 minutes

B

30 minutes

C

9 days

D

6-12 months

Question 36 Explanation:

The sixty minute interval is known as “door to balloon time” for performance of PTCA on a diagnosed MI patient.

Question 37

Which of the following classes of medications protects the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation?

A

Beta-adrenergic blockers

B

Calcium channel blockers

C

Narcotics

D

Nitrates

Question 37 Explanation:

Beta-adrenergic blockers work by blocking beta receptors in the myocardium, reducing the response to catecholamines and sympathetic nerve stimulation. They protect the myocardium, helping to reduce the risk of another infarction by decreasing myocardial oxygen demand.

Option B: Calcium channel blockers reduce the workload of the heart by decreasing the heart rate.

An 18-year-old client who recently had an URI is admitted with suspected rheumatic fever. Which assessment findings confirm this diagnosis?

A

Erythema marginatum, subcutaneous nodules, and fever

B

Tachycardia, finger clubbing, and a load S3

C

Dyspnea, cough, and palpitations

D

Dyspnea, fatigue, and synocope

Question 38 Explanation:

Diagnosis of rheumatic fever requires that the client have either two major Jones criteria or one minor criterion plus evidence of a previous streptococcal infection. Major criteria include carditis, polyarthritis, Sydenham’s chorea, subcutaneous nodules, and erythema maginatum (transient, nonprurtic macules on the trunk or inner aspects of the upper arms or thighs). Minor criteria include fever, arthralgia, elevated levels of acute phase reactants, and a prolonged PR-interval on ECG.

Question 39

Acute pulmonary edema caused by heart failure is usually a result of damage to which of the following areas of the heart?

A

Left atrium

B

Right atrium

C

Left ventricle

D

Right ventricle

Question 39 Explanation:

The left ventricle is responsible for the majority of force for the cardiac output. If the left ventricle is damaged, the output decreases and fluid accumulates in the interstitial and alveolar spaces, causing pulmonary edema.

Option A: Damage to the left atrium would contribute to heart failure but wouldn’t affect cardiac output or, therefore, the onset of pulmonary edema.

Options B and D: If the right atrium and right ventricle were damaged, right-sided heart failure would result.

Question 40

Which of the following is a compensatory response to decreased cardiac output?

A

Decreased BP

B

Alteration in LOC

C

Decreased BP and diuresis

D

Increased BP and fluid retention

Question 40 Explanation:

The body compensates for a decrease in cardiac output with a rise in BP, due to the stimulation of the sympathetic NS and an increase in blood volume as the kidneys retain sodium and water.

Option A: Blood pressure doesn’t initially drop in response to the compensatory mechanism of the body.

Option B: Alteration in LOC will occur only if the decreased cardiac output persists.

Question 41

Which of the following actions is the first priority of care for a client exhibiting signs and symptoms of coronary artery disease?

A

Decrease anxiety

B

Enhance myocardial oxygenation

C

Administer sublingual nitroglycerin

D

Educate the client about his symptoms

Question 41 Explanation:

Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate oxygenation, the myocardium suffers damage.

Options A and D: Although educating the client and decreasing anxiety are important in care delivery, neither are priorities when a client is compromised.

Option C: Sublingual nitroglycerin is administered to treat acute angina, but the administration isn’t the first priority.

Question 42

Which of the following conditions is most commonly responsible for myocardial infarction?

A

Aneurysm

B

Heart failure

C

Coronary artery thrombosis

D

Renal failure

Question 42 Explanation:

Coronary artery thrombosis causes an inclusion of the artery, leading to myocardial death.

Option A: An aneurysm is an outpouching of a vessel and doesn’t cause an MI.

Option B: Heart failure is usually a result from an MI.

Option D: Renal failure can be associated with MI but isn’t a direct cause.

Question 43

Which of the following symptoms might a client with right-sided heart failure exhibit?

A

Adequate urine output

B

Polyuria

C

Oliguria

D

Polydipsia

Question 43 Explanation:

Inadequate deactivation of aldosterone by the liver after right-sided heart failure leads to fluid retention, which causes oliguria.

Question 44

Aspirin is administered to the client experiencing an MI because of its:

A

Antipyrectic action

B

Antithrombotic action

C

Antiplatelet action

D

Analgesic action

Question 44 Explanation:

Aspirin does have antipyretic, antiplatelet, and analgesic actions, but the primary reason ASA is administered to the client experiencing an MI is its antithrombotic action.

Question 45

Which of the following would be a priority nursing diagnosis for the client with heart failure and pulmonary edema?

A

Risk for infection related to stasis of alveolar secretions

B

Impaired skin integrity related to pressure

C

Activity intolerance related to pump failure

D

Constipation related to immobility

Question 45 Explanation:

Activity intolerance is a primary problem for clients with heart failure and pulmonary edema. The decreased cardiac output associated with heart failure leads to reduced oxygen and fatigue. Clients frequently complain of dyspnea and fatigue.

Options A, B, and D: The client could be at risk for infection related to stasis of secretions or impaired skin integrity related to pressure. However, these are not the priority nursing diagnoses for the client with HF and pulmonary edema, nor is constipation related to immobility.

Question 46

Which of the following actions is the appropriate initial response to a client coughing up pink, frothy sputum?

A

Call for help

B

Call the physician

C

Start an I.V. line

D

Suction the client

Question 46 Explanation:

Production of pink, frothy sputum is a classic sign of acute pulmonary edema. Because the client is at high risk for decompensation, the nurse should call for help but not leave the room. The other three interventions would immediately follow.

Question 47

Jose, who had a myocardial infarction 2 days earlier, has been complaining to the nurse about issues related to his hospital stay. The best initial nursing response would be to:

A

Allow him to release his feelings and then leave him alone to allow him to regain his composure

B

Refocus the conversation on his fears, frustrations and anger about his condition

C

Explain how his being upset dangerously disturbs his need for rest

D

Attempt to explain the purpose of different hospital routines

Question 47 Explanation:

This provides the opportunity for the client to verbalize feelings underlying behavior and helpful in relieving anxiety. Anxiety can be a stressor which can activate the sympathoadrenal response causing the release of catecholamines that can increase cardiac contractility and workload that can further increase myocardial oxygen demand.

Question 48

A 55-year-old client is admitted with an acute inferior-wall myocardial infarction. During the admission interview, he says he stopped taking his metoprolol (Lopressor) 5 days ago because he was feeling better. Which of the following nursing diagnoses takes priority for this client?

The nurse coming on duty receives the report from the nurse going off duty. Which of the following clients should the on-duty nurse assess first?

A

The 58-year-old client who was admitted 2 days ago with heart failure, BP of 126/76, and a respiratory rate of 21 breaths a minute.

B

The 88-year-old client with end-stage right-sided heart failure, BP of 78/50, and a DNR order.

C

The 62-year-old client who was admitted one day ago with thrombophlebitis and receiving IV heparin.

D

A 76-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving IV diltiazem (Cardizem).

Question 49 Explanation:

The client with A-fib has the greatest potential to become unstable and is on IV medication that requires close monitoring. After assessing this client, the nurse should assess the client with thrombophlebitis who is receiving a heparin infusion, and then go to the 58-year-old client admitted 2-days ago with heart failure (her s/s are resolving and don’t require immediate attention). The lowest priority is the 89-year-old with end stage right-sided heart failure, who requires time consuming supportive measures.

Question 50

Stimulation of the sympathetic nervous system produces which of the following responses?

A

Bradycardia

B

Tachycardia

C

Hypotension

D

Decreased myocardial contractility

Question 50 Explanation:

Stimulation of the sympathetic nervous system causes tachycardia and increased contractility. The other symptoms listed are related to the parasympathetic nervous system, which is responsible for slowing the heart rate.

Question 51

Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse next action?

A

Call for help and note the time.

B

Clear the airway

C

Give two sharp thumps to the precordium, and check the pulse.

D

Administer two quick blows.

Question 51 Explanation:

Having established, by stimulating the client, that the client is unconscious rather than sleep, the nurse should immediately call for help. This may be done by dialing the operator from the client’s phone and giving the hospital code for cardiac arrest and the client’s room number to the operator, of if the phone is not available, by pulling the emergency call button. Noting the time is important baseline information for cardiac arrest procedure.

Question 52

Which of the following is the most common symptom of myocardial infarction (MI)?

A

Chest pain

B

Dyspnea

C

Edema

D

Palpitations

Question 52 Explanation:

The most common symptom of an MI is chest pain, resulting from deprivation of oxygen to the heart.

Option B: Dyspnea is the second most common symptom, related to an increase in the metabolic needs of the body during an MI.

Option C: Edema is a later sign of heart failure, often seen after an MI.

Which of the following interventions should be the first priority when treating a client experiencing chest pain while walking?

A

Sit the client down

B

Get the client back to bed

C

Obtain an ECG

D

Administer sublingual nitroglycerin

Question 53 Explanation:

The initial priority is to decrease the oxygen consumption; this would be achieved by sitting the client down.

Option B and D: After the ECG, sublingual nitro would be administered. When the client’s condition is stabilized, he can be returned to bed.

Option C: An ECG can be obtained after the client is sitting down.

Question 54

Which of the following classes of drugs is most widely used in the treatment of cardiomyopathy?

A

Antihypertensives

B

Beta-adrenergic blockers

C

Calcium channel blockers

D

Nitrates

Question 54 Explanation:

By decreasing the heart rate and contractility, beta-blockers improve myocardial filling and cardiac output, which are primary goals in the treatment of cardiomyopathy.

Option A: Antihypertensives aren’t usually indicated because they would decrease cardiac output in clients who are already hypotensive.

Option C: Calcium channel blockers are sometimes used for the same reasons as beta-blockers; however, they aren’t as effective as beta-blockers and cause increased hypotension.

Option D: Nitrates aren’t used because of their dilating effects, which would further compromise the myocardium.

Question 55

Which of the following arteries primarily feeds the anterior wall of the heart?

A

Circumflex artery

B

Internal mammary artery

C

Left anterior descending artery

D

Right coronary artery

Question 55 Explanation:

The left anterior descending artery is the primary source of blood for the anterior wall of the heart.

Options A, B, and D: The circumflex artery supplies the lateral wall, the internal mammary artery supplies the mammary, and the right coronary artery supplies the inferior wall of the heart.

Question 56

A patient admitted to the hospital with myocardial infarction develops severe pulmonary edema. Which of the following symptoms should the nurse expect the patient to exhibit?

A

Slow, deep respirations.

B

Stridor.

C

Bradycardia.

D

Air hunger.

Question 56 Explanation:

Patients with pulmonary edema experience air hunger, anxiety, and agitation. Respiration is fast and shallow and heart rate increases. Stridor is noisy breathing caused by laryngeal swelling or spasm and is not associated with pulmonary edema.

Question 57

A 55-year-old client is admitted with chest pain that radiates to the neck, jaw and shoulders that occurs at rest, with high body temperature, weak with generalized sweating and with decreased blood pressure. A myocardial infarction is diagnosed. The nurse knows that the most accurate explanation for one of these presenting adaptations is:

A

Catecholamines released at the site of the infarction causes intermittent localized pain.

Constriction of central and peripheral blood vessels causes a decrease in blood pressure.

D

Inflammation in the myocardium causes a rise in the systemic body temperature.

Question 57 Explanation:

Temperature may increase within the first 24 hours and persist as long as a week.

Question 58

Which of the following positions would best aid breathing for a client with acute pulmonary edema?

A

Lying flat in bed

B

Left side-lying

C

In high Fowler’s position

D

In semi-Fowler’s position

Question 58 Explanation:

A high Fowler’s position promotes ventilation and facilitates breathing by reducing venous return.

Options A and B: Lying flat and side-lying positions worsen the breathing and increase the workload of the heart.

Option D: Semi-Fowler’s position won’t reduce the workload of the heart as well as the Fowler’s position will.

Question 59

Alzheimer’s disease is the secondary diagnosis of a client admitted with myocardial infarction. Which nursing intervention should appear on this client’s plan of care?

A

Perform activities of daily living for the client to decease frustration.

B

Provide a stimulating environment.

C

Establish and maintain a routine.

D

Try to reason with the client as much as possible.

Question 59 Explanation:

Establishing and maintaining a routine is essential to decreasing extraneous stimuli. The client should participate in daily care as much as possible. Attempting to reason with such clients isn’t successful, because they can’t participate in abstract thinking.

Question 60

What is the first intervention for a client experiencing MI?

A

Administer morphine

B

Administer oxygen

C

Administer sublingual nitroglycerin

D

Obtain an ECG

Question 60 Explanation:

Administering supplemental oxygen to the client is the first priority of care. The myocardium is deprived of oxygen during an infarction, so additional oxygen is administered to assist in oxygenation and prevent further damage.

Options A and C: Morphine and nitro are also used to treat MI, but they’re more commonly administered after the oxygen.

Option D: An ECG is the most common diagnostic tool used to evaluate MI.

Question 61

Mr. Duffy is admitted to the CCU with a diagnosis of R/O MI. He presented in the ER with a typical description of pain associated with an MI, and is now cold and clammy, pale and dyspneic. He has an IV of D5W running, and is complaining of chest pain. Oxygen therapy has not been started, and he is not on the monitor. He is frightened.
During the first three days that Mr. Duffy is in the CCU, a number of diagnostic blood tests are obtained. Which of the following patterns of cardiac enzyme elevation are most common following an MI?

Tissue plasminogen activator (t-PA) is considered for treatment of a patient who arrives in the emergency department following onset of symptoms of myocardial infarction. Which of the following is a contraindication for treatment with t-PA?

A

Worsening chest pain that began earlier in the evening.

B

History of cerebral hemorrhage.

C

History of prior myocardial infarction.

D

Hypertension.

Question 64 Explanation:

A history of cerebral hemorrhage is a contraindication to tPA because it may increase the risk of bleeding. TPA acts by dissolving the clot blocking the coronary artery and works best when administered within 6 hours of onset of symptoms. Prior MI is not a contraindication to tPA. Patients receiving tPA should be observed for changes in blood pressure, as tPA may cause hypotension.

Question 65

Which patient’s nursing care would be most appropriate for the charge nurse to assign to the LPN, under the supervision of the RN team leader?

A

A 51-year-old patient with bilateral adrenalectomy just returned from the post-anesthesia care unit

The 83-year-old patient has no complicating factors at the moment. Providing care for stable and uncomplicated patients is within the LPN’s educational preparation and scope of practice, with the care always being provided under the supervision and direction of the RN. The RN should assess the newly post-operative patient and the new admission. The patient who is preparing for discharge after MI may need some complex teaching. Focus: Delegation/supervision, assignment

Question 66

A male client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can’t produce an effective cough, the nurse should monitor closely for:

A

Pleural effusion.

B

Pulmonary edema.

C

Atelectasis.

D

Oxygen toxicity.

Question 66 Explanation:

In a client with COPD, an ineffective cough impedes secretion removal. This, in turn, causes mucus plugging, which leads to localized airway obstruction — a known cause of atelectasis. An ineffective cough doesn’t cause pleural effusion (fluid accumulation in the pleural space). Pulmonary edema usually results from left-sided heart failure, not an ineffective cough. Although many noncardiac conditions may cause pulmonary edema, an ineffective cough isn’t one of them. Oxygen toxicity results from prolonged administration of high oxygen concentrations, not an ineffective cough.

Question 67

Captopril may be administered to a client with HF because it acts as a:

A

Vasopressor

B

Volume expander

C

Vasodilator

D

Potassium-sparing diuretic

Question 67 Explanation:

ACE inhibitors have become the vasodilators of choice in the client with mild to severe HF. Vasodilator drugs are the only class of drugs clearly shown to improve survival in overt heart failure.

Question 68

A nurse caring for several patients on the cardiac unit is told that one is scheduled for implantation of an automatic internal cardioverter-defibrillator. Which of the following patients is most likely to have this procedure?

A

A patient admitted for myocardial infarction without cardiac muscle damage.

B

A post-operative coronary bypass patient, recovering on schedule.

C

A patient with a history of ventricular tachycardia and syncopal episodes.

D

A patient with a history of atrial tachycardia and fatigue.

Question 68 Explanation:

An automatic internal cardioverter-defibrillator delivers an electric shock to the heart to terminate episodes of ventricular tachycardia and ventricular fibrillation. This is necessary in a patient with significant ventricular symptoms, such as tachycardia resulting in syncope. A patient with myocardial infarction that resolved with no permanent cardiac damage would not be a candidate. A patient recovering well from coronary bypass would not need the device. Atrial tachycardia is less serious and is treated conservatively with medication and cardioversion as a last resort.

Question 69

Which of the following results is the primary treatment goal for angina?

A

Reversal of ischemia

B

Reversal of infarction

C

Reduction of stress and anxiety

D

Reduction of associated risk factors

Question 69 Explanation:

Reversal of the ischemia is the primary goal, achieved by reducing oxygen consumption and increasing oxygen supply.

Option B: An infarction is permanent and can’t be reversed.

Question 70

After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate to suggest?

Canned fish and vegetables and cured meats are high in sodium. This meal does not contain any canned fish and/or vegetables or cured meats

Question 71

In which of the following disorders would the nurse expect to assess sacral edema in a bedridden client?

A

Diabetes

B

Pulmonary emboli

C

Renal failure

D

Right-sided heart failure

Question 71 Explanation:

The most accurate area on the body to assess dependent edema in a bed-ridden client is the sacral area. Sacral, or dependent, edema is secondary to right-sided heart failure.

Question 72

A nurse is conducting a health history with a client with a primary diagnosis of heart failure. Which of the following disorders reported by the client is unlikely to play a role in exacerbating the heart failure?

A nurse is preparing to ambulate a client on the 3rd day after cardiac surgery. The nurse would plan to do which of the following to enable the client to best tolerate the ambulation?

A

Encourage the client to cough and deep breathe

B

Premedicate the client with an analgesic

C

Provide the client with a walker

D

Remove telemetry equipment because it weighs down the hospital gown.

Question 76 Explanation:

The nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery because analgesia will promote rest, decrease myocardial oxygen consumption resulting from pain, and allow better participation in activities such as coughing, deep breathing, and ambulation.

A client admitted with angina compains of severe chest pain and suddenly becomes unresponsive. After establishing unresponsiveness, which of the following actions should the nurse take first?

A

Activate the resuscitation team

B

Open the client’s airway

C

Check for breathing

D

Check for signs of circulation

Question 77 Explanation:

Immediately after establishing unresponsiveness, the nurse should activate the resuscitation team. The next step is to open the airway using the head-tilt, chin-lift maneuver and check for breathing (looking, listening, and feeling for no more than 10-seconds). If the client isn’t breathing, give two slow breaths using a bag mask or pocket mask. Next, check for signs of circulation by palpating the carotid pulse.

Question 78

The nurse should visit which of the following clients first?

A

The client with diabetes with a blood glucose of 95mg/dL

B

The client with hypertension being maintained on Lisinopril

C

The client with hypertension being maintained on Lisinopril

D

The client with Raynaud’s disease

Question 78 Explanation:

The client with chest pain should be seen first because this could indicate a myocardial infarction. The client in answer A has a blood glucose within normal limits. The client in answer B is maintained on blood pressure medication. The client in answer D is in no distress.

Question 79

What is the primary reason for administering morphine to a client with myocardial infarction?

A

To sedate the client

B

To decrease the client's pain

C

To decrease the client's anxiety

D

To decrease oxygen demand on the client's heart

Question 79 Explanation:

Morphine is administered because it decreases myocardial oxygen demand. Morphine will also decrease pain and anxiety while causing sedation, but isn't primarily given for those reasons.

Question 80

A client’s electrocardiogram strip shows atrial and ventricular rates of 80 complexes per minute. The PR interval is 0.14 second, and the QRS complex measures 0.08 second. The nurse interprets this rhythm is:

A

Normal sinus rhythm

B

Sinus bradycardia

C

Sinus tachycardia

D

Sinus dysrhythmia

Question 81

Patrick who is hospitalized following a myocardial infarction asks the nurse why he is taking morphine. The nurse explains that morphine:

A

Decrease anxiety and restlessness

B

Prevents shock and relieves pain

C

Dilates coronary blood vessels

D

Helps prevent fibrillation of the heart

Question 81 Explanation:

Morphine is a central nervous system depressant used to relieve the pain associated with myocardial infarction, it also decreases apprehension and prevents cardiogenic shock.

Question 82

A home care nurse is making a routine visit to a client receiving digoxin (Lanoxin) in the treatment of heart failure. The nurse would particularly assess the client for:

A

Thrombocytopenia and weight gain

B

Anorexia, nausea, and visual disturbances

C

Diarrhea and hypotension

D

Fatigue and muscle twitching

Question 82 Explanation:

The first signs and symptoms of digoxin toxicity in adults include abdominal pain, N/V, visual disturbances (blurred, yellow, or green vision, halos around lights), bradycardia, and other dysrhythmias.

Question 83

A nurse is preparing for the admission of a client with heart failure who is being sent directly to the hospital from the physician’s office. The nurse would plan on having which of the following medications readily available for use?

A

Diltiazem (Cardizem)

B

Digoxin (Lanoxin)

C

Propranolol (Inderal)

D

Metoprolol (Lopressor)

Question 83 Explanation:

Digoxin exerts a positive inotropic effect on the heart while slowing the overall rate through a variety of mechanisms. Digoxin is the medication of choice to treat heart failure.

Options A, C, and D: Diltiazem (calcium channel blocker) and propranolol and metoprolol (beta blockers) have a negative inotropic effect and would worsen the failing heart.

Question 84

Nursing measures for the client who has had an MI include helping the client to avoid activity that results in Valsalva’s maneuver. Valsalva’s maneuver may cause cardiac dysrhythmias, increased venous pressure, increased intrathoracic pressure and thrombi dislodgement. Which of the following actions would help prevent Valsalva’s maneuver? Have the client:

A

Assume a side-lying position

B

Clench her teeth while moving in bed

C

Drink fluids through a straw

D

Avoid holding her breath during activity

Question 85

Which of the following blood gas abnormalities is initially most suggestive of pulmonary edema?

A

Anoxia

B

Hypercapnia

C

Hyperoxygenation

D

Hypocapnia

Question 85 Explanation:

In an attempt to compensate for increased work of breathing due to hyperventilation, carbon dioxide decreases, causing hypocapnea. If the condition persists, CO2 retention occurs and hypercapnia results.

Question 86

Which of the following cardiac conditions does a fourth heart sound (S4) indicate?

A

Dilated aorta

B

Normally functioning heart

C

Decreased myocardial contractility

D

Failure of the ventricle to eject all of the blood during systole

Question 86 Explanation:

An S4 occurs as a result of increased resistance to ventricular filling after atrial contraction. The increased resistance is related to decreased compliance of the ventricle.

Option A: A dilated aorta doesn’t cause an extra heart sound, though it does cause a murmur.

Option B: An S4 isn’t heard in a normally functioning heart.

Option C: Decreased myocardial contractility is heard as a third heart sound.

Question 87

Which of the following types of angina is most closely related with an impending MI?

A

Angina decubitus

B

Chronic stable angina

C

Noctural angina

D

Unstable angina

Question 87 Explanation:

Unstable angina progressively increases in frequency, intensity, and duration and is related to an increased risk of MI within 3 to 18 months.

Question 88

When developing a teaching plan for a client with endocarditis, which of the following points is most essential for the nurse to include?

A

“Report fever, anorexia, and night sweats to the physician.”

B

“Take prophylactic antibiotics after dental work and invasive procedures.”

C

“Include potassium rich foods in your diet.”

D

“Monitor your pulse regularly.”

Question 88 Explanation:

An essential teaching point is to report signs of relapse, such as fever, anorexia, and night sweats, to the physician.

Option B: To prevent further endocarditis episodes, prophylactic antibiotics are taken before and sometimes after dental work, childbirth, or GU, GI, or gynecologic procedures.

Options C and D: A potassium-rich diet and daily pulse monitoring aren’t necessary for a client with endocarditis.

Question 89

Helen, a nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with:

A

Dopamine drip IV with vital signs monitored every 5 minutes

B

a myocardial infarction that is free from pain and dysrhythmias

C

a tracheotomy of 24 hours in some respiratory distress

D

a pacemaker inserted this morning with intermittent capture

Question 89 Explanation:

This client is the most stable with minimal risk of complications or instability. The nurse can utilize basic nursing skills to care for this client.

Question 90

To prevent a valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would

A

Assist the client to use the bedside commode

B

Administer stool softeners every day as ordered

C

Administer antidysrhythmics prn as ordered

D

Maintain the client on strict bed rest

Question 90 Explanation:

Administering stool softeners every day will prevent straining on defecation which causes the Valsalva maneuver. If constipation occurs then laxatives would be necessary to prevent straining. If straining on defecation produced the valsalva maneuver and rhythm disturbances resulted then antidysrhythmics would be appropriate.

Question 91

Which of the following reflects the principle on which a client’s diet will most likely be based during the acute phase of MI?

A

Liquids as ordered

B

Small, easily digested meals

C

Three regular meals per day

D

NPO

Question 91 Explanation:

Recommended dietary principles in the acute phase of MI include avoiding large meals because small, easily digested foods are better digested foods are better tolerated. Fluids are given according to the client’s needs, and sodium restrictions may be prescribed, especially for clients with manifestations of heart failure. Cholesterol restrictions may be ordered as well.

Options A and D: Clients are not prescribed a diet of liquids only or NPO unless their condition is very unstable.

Question 92

Which of the following blood tests is most indicative of cardiac damage?

A

Lactate dehydrogenase

B

Complete blood count (CBC)

C

Troponin I

D

Creatine kinase (CK)

Question 92 Explanation:

Troponin I levels rise rapidly and are detectable within 1 hour of myocardial injury. Troponin I levels aren’t detectable in people without cardiac injury.

Option A: Lactate dehydrogenase (LDH) is present in almost all body tissues and not specific to heart muscle. LDH isoenzymes are useful in diaagnosing a cardiac injury.

Option B: CBC is obtained to review blood counts, and a complete chemistry is obtained to review electrolytes.

Option D: Because CK levels may rise with a skeletal muscle injury, CK isoenzymes are required to detect cardiac injury.

Question 93

Furosemide is administered intravenously to a client with HF. How soon after administration should the nurse begin to see evidence of the drugs desired effect?

A

5 to 10 minutes

B

30 to 60 minutes

C

2 to 4 hours

D

6 to 8 hours

Question 93 Explanation:

After IV injection of furosemide, diuresis normally begins in about 5 minutes and reaches its peak within about 30 minutes. Medication effects last 2 to 4 hours.

Question 94

Which statement best describes the difference between the pain of angina and the pain of myocardial infarction?

A

Pain associated with angina is relieved by rest.

B

Pain associated with myocardial infarction is always more severe.

C

Pain associated with angina is confined to the chest area.

D

Pain associated with myocardial infarction is referred to the left arm.

Question 94 Explanation:

Pain associated with angina is relieved by rest. Answer B is incorrect because it is not a true statement. Answer Pain associated with angina is confined to the chest area is incorrect because pain associated with angina can be referred to the jaw, the left arm, and the back. Pain associated with myocardial infarction is referred to the left arm is incorrect because pain from a myocardial infarction can be referred to areas other than the left arm.

Question 95

A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac stepdown unit (CSU). While giving report to the CSU nurse, the CCU nurse says, “His pulmonary artery wedge pressures have been in the high normal range.” The CSU nurse should be especially observant for:

Which of the following types of cardiomyopathy can be associated with childbirth?

A

Dilated

B

Hypertrophic

C

Myocarditis

D

Restrictive

Question 99 Explanation:

Although the cause isn’t entirely known, cardiac dilation and heart failure may develop during the last month of pregnancy or the first few months after birth. The condition may result from a preexisting cardiomyopathy not apparent prior to pregnancy.

Option B: Hypertrophic cardiomyopathy is an abnormal symmetry of the ventricles that has an unknown etiology but a strong familial tendency.

The greatest danger of an uncorrected atrial fibrillation for a male patient will be which of the following:

A

Pulmonary embolism

B

Cardiac arrest

C

Thrombus formation

D

Myocardial infarction

Question 102

What is the primary reason for administering morphine to a client with an MI?

A

To sedate the client

B

To decrease the client’s pain

C

To decrease the client’s anxiety

D

To decrease oxygen demand on the client’s heart

Question 102 Explanation:

Morphine is administered because it decreases myocardial oxygen demand.

Options A, B, and C: Morphine will also decrease pain and anxiety while causing sedation, but it isn’t primarily given for those reasons.

Question 103

Toxicity from which of the following medications may cause a client to see a green-yellow halo around lights?

A

Digoxin

B

Furosemide (Lasix)

C

Metoprolol (Lopressor)

D

Enalapril (Vasotec)

Question 103 Explanation:

One of the most common signs of digoxin toxicity is the visual disturbance known as the “green-yellow halo sign.” The other medications aren’t associated with such an effect.

Question 104

A client with angina complains that the angina pain is prolonged and severe and occurs at the same time each day, most often in the morning, On further assessment a nurse notes that the pain occurs in the absence of precipitating factors. This type of anginal pain is best described as:

A

Stable angina

B

Unstable angina

C

Variant angina

D

Nonanginal pain

Question 104 Explanation:

Variant angina, or Prinzmetal’s angina, is prolonged and severe and occurs at the same time each day, most often in the morning.

Option A: Stable angina is induced by exercise and is relieved by rest or nitroglycerin tablets.

Option B: Unstable angina occurs at lower and lower levels of activity and rest, is less predictable and is often a precursor of myocardial infarction.

Question 105

With which of the following disorders is jugular vein distention most prominent?

A

Abdominal aortic aneurysm

B

Heart failure

C

MI

D

Pneumothorax

Question 105 Explanation:

Elevated venous pressure, exhibited as jugular vein distention, indicates a failure of the heart to pump.

Options A and D: JVD isn’t a symptom of abdominal aortic aneurysm or pneumothorax.

Option C: An MI, if severe enough, can progress to heart failure, however, in and of itself, an MI doesn’t cause JVD.

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Nursing Care Plan

Nursing Priorities

Relieve pain, anxiety.

Reduce myocardial workload.

Prevent/detect and assist in treatment of life-threatening dysrhythmias or complications.

Promote cardiac health, self-care.

Nursing diagnosis: Pain, Acute

May be related to

Tissue ischemia (coronary artery occlusion)

Possibly evidenced by

Reports of chest pain with/without radiation

Facial grimacing

Restlessness, changes in level of consciousness

Changes in pulse, BP

Desired outcomes/evaluation criteria—patient will:

Pain Level (NOC)

Verbalize relief/control of chest pain within appropriate time frame for administered medications.

Variation of appearance and behavior of patients in pain may present a challenge in assessment. Most patients with an acute MI appear ill, distracted, and focused on pain. Verbal history and deeper investigation of precipitating factors should be postponed until pain is relieved. Respirations may be increased as a result of pain and associated anxiety; release of stress-induced catecholamines increases heart rate and BP.

Obtain full description of pain from patient including location, intensity (0–10),duration,characteristics(dull/crushing), and radiation. Assist patient to quantify pain by comparing it to other experiences.

Pain is a subjective experience and must be described by patient. Provides baseline for comparison to aid in determining effectiveness of therapy, resolution/progression of problem.

Review history of previous angina, anginal equivalent, or MI pain. Discuss family history if pertinent.

May differentiate current pain from preexisting patterns, as well as identify complications such as extension of infarction, pulmonary embolus, or pericarditis.

Instruct patient to report pain immediately.

Delay in reporting pain hinders pain relief/may require increased dosage of medication to achieve relief. In addition, severe pain may induce shock by stimulating the sympathetic nervous system, thereby creating further damage and interfering with diagnostics and relief of pain.

Important second-line agents for pain control through effect of blocking sympathetic stimulation, thereby reducing heart rate, systolic BP, and myocardial oxygen demand. May be given alone or with nitrates. Note: beta-blockers may be contraindicated if myocardial contractility is severely impaired, because negative inotropic properties can further reduce contractility.

Analgesics, e.g., morphine, meperidine (Demerol)

Although intravenous (IV) morphine is the usual drug of choice, other injectable narcotics may be used in acute-phase/recurrent chest pain unrelieved by nitroglycerin to reduce severe pain, provide sedation, and decrease myocardial workload. IM injections should be avoided, if possible, because they can alter the CPK diagnostic indicator and are not well absorbed in underperfused tissue.

Record/document heart rate and rhythm and BP changes before, during, and after activity, as indicated. Correlate with reports of chest pain/shortness of breath. (Refer to ND: Cardiac Output, risk for decreased.)

Trends determine patient’s response to activity and may indicate myocardial oxygen deprivation that may require decrease in activity level/return to bedrest, changes in medication regimen, or use of supplemental oxygen.

Reduces myocardial workload/oxygen consumption, reducing risk of complications (e.g., extension of MI).Note: American Heart Association/American College of Cardiology guidelines (1996) suggest that patients with cardiac conditions should not be kept in bed longer than 24 hr. Patients with uncomplicated MI are encouraged to engage in mild activity out of bed, including short walks 12 hr after incident.

Coping with the pain and emotional trauma of an MI is difficult. Patient may fear death and/or be anxious about immediate environment. Ongoing anxiety (related to concerns about impact of heart attack on future lifestyle, matters left unattended/unresolved, and effects of illness on family) may be present in varying degrees for some time and may be manifested by symptoms of depression.

Research into survival rates between type A and type B individuals and the impact of denial has been ambiguous; however, studies show some correlation between degree/expression of anger or hostility and an increased risk for MI.

Maintain confident manner (without false reassurance).

Patient and SO can be affected by the anxiety/uneasiness displayed by health team members. Honest explanations can alleviate anxiety.

Observe for verbal/nonverbal signs of anxiety, and stay with patient. Intervene if patient displays destructive behavior.

Patient may not express concern directly, but words/actions may convey sense of agitation, aggression, and hostility. Intervention can help patient regain control of own behavior.

Nursing Interventions

Rationale

Anxiety Reduction

Independent

Accept but do not reinforce use of denial. Avoid confrontations.

Denial can be beneficial in decreasing anxiety but can postpone dealing with the reality of the current situation. Confrontation can promote anger and increase use of denial, reducing cooperation and possibly impeding recovery.

Accurate information about the situation reduces fear, strengthens nurse-patient relationship, and assists patient/SO to deal realistically with situation. Attention span may be short, and repetition of information helps with retention.

Encourage patient/SO to communicate with one another, sharing questions and concerns.

Hypotension may occur related to ventricular dysfunction, hypoperfusion of the myocardium, and vagal stimulation. However, hypertension is also a common phenomenon, possibly related to pain, anxiety, catecholamine release, and/or preexisting vascular problems. Orthostatic (postural) hypotension may be associated with complications of infarct, e.g., HF.

S3 is usually associated with HF, but it may also be noted with the mitral insufficiency (regurgitation) and left ventricular overload that can accompany severe infarction. S4 may be associated with myocardial ischemia, ventricular stiffening, and pulmonary or systemic hypertension.

Presence of murmurs/rubs.

Indicates disturbances of normal blood flow within the heart, e.g., incompetent valve, septal defect, or vibration of papillary muscle/chordae tendineae (complication of MI). Presence of rub with an infarction is also associated with inflammation, e.g., pericardial effusion and pericarditis.

Heart rate and rhythm respond to medication, activity, and developing complications. Dysrhythmias (especially premature ventricular contractions or progressive heart blocks) can compromise cardiac function or increase ischemic damage. Acute or chronic atrial flutter/fibrillation may be seen with coronary artery or valvular involvement and may or may not be pathological.

Measure cardiac output and other functional parameters as appropriate.

Cardiac index, preload/afterload, contractility, and cardiac work can be measured noninvasively with thoracic electrical bioimpedance (TEB) technique. Useful in evaluating response to therapeutic interventions and identifying need for more aggressive/emergency care.

Maintain IV/Hep-Lock access as indicated.

Patent line is important for administration of emergency drugs in presence of persistent lethal dysrhythmias or chest pain.

Dysrhythmias are usually treated symptomatically, except for PVCs, which are often treated prophylactically. Early inclusion of ACE inhibitor therapy (especially in presence of large anterior MI, ventricular aneurysm, or HF) enhances ventricular output, increases survival, and may slow progression of HF. Note: Use of routine lidocaine is no longer recommended.

Assist with insertion/maintain pacemaker, when used.

Pacing may be a temporary support measure during acute phase or may be needed permanently if infarction severely damages conduction system, impairing systolic function. Evaluation is based on echocardiography or radionuclide ventriculography.

Reduces mortality in MI patients, and is taken daily. Aspirin also reduces coronary reocclusion after percutaneous transluminal coronary angioplasty (PTCA). ReoPro is an IV drug used as an adjunct to PTCA for prevention of acute ischemic complications.

Anticoagulants, e.g., heparin/enoxaparin (Lovenox);

Low-dose heparin is given during PTCA and may be given prophylactically in high-risk patients (e.g., atrial fibrillation, obesity, ventricular aneurysm, or history of thrombophlebitis) to reduce risk of thrombophlebitis or mural thrombus formation.

Oral anticoagulants, e.g., anisindione (Miradon), warfarin (Coumadin)

Used for prophylaxis and treatment of thromboembolic complications associated with MI.

This procedure is used to open partially blocked coronary arteries before they become totally blocked. The mechanism includes a combination of vessel stretching and plaque compression. Intracoronary stents may be placed at the time of PTCA to provide structural support within the coronary artery and improve the odds of long-term patency.

Transfer to critical care.

More intensive monitoring and aggressive interventions are necessary to promote optimum outcome.

Necessary for creation of individual instruction plan.Reinforces expectation that this will be a “learning experience.” Verbalization identifies misunderstandings and allows for clarification.

Be alert to signs of avoidance, e.g., changing subject away from information being presented or extremes of behavior (withdrawal/euphoria).

Natural defense mechanisms, such as anger or denial of significance of situation, can block learning, affecting patient’s response and ability to assimilate information. Changing to a less formal/structured style may be more effective until patient/SO is ready to accept/deal with current situation.

Provides opportunity for patient to retain information and to assume control/participate in rehabilitation program.Note: Routine use of supplements/herbal remedies (e.g., ginkgo biloba, garlic, vitamin E) can result in alterations in blood clotting, especially when anticoagulant/ASA therapy is prescribed.

Reinforces that this is an ongoing/continuing health problem for which support/assistance is available after discharge. Note: After discharge, patients encounter limitations in physical functioning and often incur difficulty with emotional, social, and role functioning requiring ongoing support.

Emphasize importance of contacting physician if chest pain, change in anginal pattern, or other symptoms recur.

Timely evaluation/intervention may prevent complications.

Stress importance of reporting development of fever in association with diffuse/atypical chest pain (pleural, pericardial) and joint pain.

Depressed patients have a greater risk of dying 6–18 mo following a heart attack. Timely intervention may be beneficial. Note: Selective serotonin reuptake inhibitors (SSRIs), e.g., paroxetine (Paxil), have been found to be as effective as tricyclic antidepressants but with significantly fewer adverse cardiac complications.

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